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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
The Importance of Context
Narrative Based Medicine
Chronic Illness Management in the Real World
Weighty Matters
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Dean G. Gianakos, Lynchburg, VA USA Physician, Lynchburg Family Medicine Residency
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I very much appreciate the comments of Reis, Scott, and Shapiro. All three point to the importance of "context" when making clinical decisions. In my view, it takes a long time- longer than a residency, certainly- to get really comfortable with this notion. Indeed, it takes courage to make decisions that don't jive with the latest evidence-based guidelines. Will the patient's family sue me if he or she dies? What will my attending say when she reads my note? What conversations do I have with myself about having a poorly controlled asthmatic patient- in other words, what kind of doctor am I? It takes a long time to say to yourself: relax. Keep building the relationship. I can only do my best, imperfect as it is, to figure out what medical decision best fits the patient's value system. That decision, as the authors point out, does not always match the guidelines. The "figuring out" is what the relationship/conversation is about. The "figuring out" is one of the challenges-and joys- of medicine. Dean Gianakos, MD Competing interests: None declared |
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Shmuel Reis, Atzmon, Israel Chair of Family Medicine & Medical Ed., Rappaport Faculty of Medicine, The Technion, Haifa, Israel
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I just went to my Family Doc this week realizing I haven't checked my elevated cholesterol for a few years. I excused myself previously that in a few weeks, when I took a few more pounds off will be the right moment, which never came. And she is not Sally but Miriam and 93 years old and it is not COPD but …and mind you, I live and practice 10000 miles away and in a different language. In the real world of care, most of the time clinical decisions are taken from the contextual point of view and not according to the evidence (after considering it, hopefully). While doing so, while reflecting on your own healer and person narrative both patient and physician may heal and grow (1 ). A special type of doc's narratives (2) is that which touch "forbidden conversations", those deeds and thoughts that you sometimes whisper in the ear of your closest friend. Mac Baird taught me about it over a decade ago and in a recent AAPP course I learned some more. Sharing those is a special privilege.Thank you , Dean. 1. Reis S, Hermoni D, Livingstone P, Borkan J. An Integrated Narrative- and Evidence-Based Case Report: A Case Report of Paroxysmal Atrial Fibrillation and Anticoagulation. BMJ 2002 ; 325: 1018-1020. 2. Borkan J; Reis S; Steinmatz D; Medalie J. Patients and Doctors: Life-Changing Stories From Primary Care. Wisconsin University Press 1999. Competing interests: None declared |
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John G. Scott, Somerset, New Jersey, USA Assistant Professor of Family Medicine - UMDNJ-RWJMS
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I want Dr. Gianakos to be my doctor! His essay illustrates the doctor-patient relationship at its best. This experienced physician does not need to maintain “emotional distance” and he is not afraid to expose his own human failings to his patient, yet in no way does he compromise his professionalism. He respects Sally’s unique perspective about the management of her asthma, even though he would like her to do things differently. He and Sally have negotiated a treatment plan that works for both of them. The fact that this plan would fail the test of adherence to the asthma guidelines(1) only illuminates the limitations of the guidelines approach to the management of chronic illness. Clearly Sally and Dr. Gianakos have had a long history together. Time has worn the edges off of their relationship. They understand each other’s strengths and weaknesses in a way that would not be possible without this aspect of continuity between them. In this age of managed care, such continuity between a patient and physician is becoming more and more difficult to achieve and maintain.(2) It is reassuring to see that this physician and this patient have maintained their long relationship despite the barriers. The abstract suggests that this is a story about a noncompliant patient and a noncompliant doctor. I disagree, and I think we should stop using this term in clinical medicine. It implies a paternalistic relationship that is the antithesis of how doctors and patients should be connecting and it certainly is not the relationship described in this essay. Management of chronic illness is always embedded in the context of the rich fabric of the patient’s life as well as the ongoing relationship with his/her physician. That management needs to be informed by available scientific knowledge, but the form it takes will be different for each patient and physician. As Dr. Gianakos so eloquently puts it, “Not much I can teach a spunky 91 year-old woman about how to live her life.” References 1. Guidelines for the Diagnosis and Management of Asthma: National Institutes of Health National Heart Lung and Blood Institute; July 1997 1997. NIH Publication 97-4051. 2. Flocke SA, Stange KC, Zyzanski SJ. The impact of insurance type and forced discontinuity on the delivery of primary care J Fam Pract. 1997;45(2):129-135. Competing interests: None declared |
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johanna shapiro, Irvine, California, USA Professor, Dept. Family Medicine; Director, Program in Medical Humanities UCI College of Medicine
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Stories like Dean Gianakos' "Pounds make me smile, because they reassure me that someone, somewhere, is still practicing family medicine the way I conceive it is meant to be practiced - with awareness and reflexivity, humility, compassion, negotiation, compromise, and humor. The tale of Sally, her asthma, and her self-reliant pride is grounded in the detailed personal knowledge her doctor has of her life, values, personality, and priorities. Furthermore, it is at least as much a tale of the physician-narrator, his high cholesterol, and his love of lemon pound cake as it is Sally's story. "Pounds recognizes that "noncompliance" is too often merely a modernist formulation of power and herarchy used to shame, blame, and distance from patients who confound us. Fortunately, Dr. Gianakos is willing to deconstruct it for us, so that in the end we are reminded that physical health is only meaningful within the context of a person's lived life. Sometimes we don't take medications because, even though they might make us feel better, they also make us feel worse by threatening some core essence; sometimes we eat "unhealthy" foods, even though we know they aren't good for us, because of the cultural, familial, and relational ties of love and affection they embody. Sometimes doctors and patients are two struggling people, bound by a shared history, the difficult times and the small triumpths both, who in relationship have the capacity to sometimes make each other's lives a little easier. It's so simple. Sometimes practicing family medicine really is a piece of cake! Competing interests: None declared |
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